The cerebellum is not only important for motor functions, but also affects a wide range of cognitive tasks including executive functions, spatial perception, language and speech, and affective functions. This was highlighted by Schmahmann and Sherman1 in their description and conceptualization of the cerebellar cognitive affective syndrome (CCAS). Since then, the impact of the cerebellum on cognitive functions has been increasingly shown in cerebellar malformations.2 Even though the pattern of cognitive impairment in cerebellar malformations is less specific than in acquired focal cerebellar lesions, it is still reminiscent of the CCAS. The anatomical basis of the cerebellar role in higher cognitive functions is the existence of cerebro-cerebellar connections (cortico-ponto-cerebellar and cerebello-thalamo-cortical loops) that link the cerebellum with associative regions in the prefrontal, posterior parietal, superior temporal polymodal regions, and dorsal parastriate cortices as well as with the limbic/paralimbic regions. The interaction between cerebellum and cerebrum may affect the anatomical structures involved in terms of volume. In preterm infants, unilateral cerebral parenchymal brain injuries have been shown to result in subsequent impairment in the contralateral cerebellar volume and, conversely, primary unilateral cerebellar injuries were reported to be associated with impaired contralateral cerebral brain volume at term.3 Bolduc et al.4 demonstrate that cerebellar volumetric impairment is associated with altered growth in specific cerebral regions and attribute this to cerebellar malformations.5 Although the small number of children included and the heterogeneous cohort of patients may be limitations of the study (in terms of different cerebellar malformations), the authors demonstrated significantly reduced volume in the deep grey matter nuclei, inferior occipital grey matter, and subgenual and midtemporal white matter. The developing cerebrum, therefore, appears to require an intact cerebellum to achieve its normal structure and volume as the result of a trophic transynaptic effect. The authors hypothesize that the associated regional reductions in cerebral volumes may represent a possible mechanism underlying developmental disabilities and cognitive impairment in children with cerebellar malformations. The interaction between cerebellum and cerebrum, however, is not limited only to a trophic transsynaptic effect, but may also lead to a cerebral cortical functional impairment. The posterior fossa syndrome is a particularly acute form of the CCAS characterized by cerebellar dysfunction, oromotor apraxia, emotional lability, and mutism in patients after infratentorial injury. This syndrome is a good example of functionally disrupted cerebro-cerebellar connections.6 In children with the posterior fossa syndrome, low fractional anisotropy values in the bilateral superior cerebellar peduncles, bilateral fornices, white matter region proximate to the right angular gyrus, and white matter region proximate to the left superior frontal gyrus have been found.6 These results show that proximal lesions of the dentato-thalamo-cortical pathway may lead to a functional disconnection between the cerebellum and the associate cortical regions and, subsequently, cause the characteristic neurocognitive impairment in the posterior fossa syndrome. I am not aware of any study in the literature showing cerebro-cerebellar functional disconnection in cerebellar malformations. It is plausible that in cerebellar malformations, both regional reductions in cerebral volumes due to a transynaptic trophic effect as well as functional disconnection in the cerebro-cerebellar white matter pathway may play a pathogenetic role causing cognitive problems. The combination of volumetric and connectivity studies may further increase our understanding of the role of the cerebellum in cognitive functions.
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